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According to one definition of social exclusion, ‘An individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives’ (Burchardt et al, 2002, p. 30). These key activities include education, employment, access to leisure facilities and civic participation. As this book documents, people who have mental illness are often excluded from some if not all of these activities. Those with the more severe forms of disorder are unlikely to be employed, more likely to reside in shared and subsidised accommodation, live in material poverty, rely on welfare benefits, and have restricted social networks and limited access to opportunities and leisure facilities in the community. Explaining this exclusion is tricky because it clearly arises in part from the nature of mental illness. Some of the more severe disorders begin in childhood and impair educational attainment that in turn limits occupational opportunity in adult life; people with depression withdraw from social contact and those with chronic schizophrenia neglect their environment. But clearly, as the term exclusion implies, much of the problem lies not with the mentally ill person but with the rest of us – how we structure society, the rules and regulations that facilitate access to education and employment, and how we go about organising assistance for the disadvantaged. Some mentally ill people, coming from a migrant group perceived as competing for jobs and resources or who are marginalised because they do not speak English or have a black skin, can have a double or triple whammy, as evidenced by the striking over-representation of some of these groups in coercive treatment settings (Bermingham et al, 1996; Coid et al, 2000; Audini & Lelliott, 2002).

How we organise care is itself confounded by our prejudices and beliefs about the capabilities of the mentally ill person and how much we generalise from observing a specific impairment to an assumption of global incompetence. On the one hand is the view that the affected individual is essentially powerless to change their state and the caring response is therefore one of doing ‘for’ the individual. On the other hand is the belief that however profound is the appearance of the disability, people have the capacity to make positive adaptations, so that providing care is a matter of teaching and giving advice to help the individual solve or work round their problems.

Research into the use of digital technology to deliver treatment for psychosis is turning up some fascinating applications, but enthusiasm for these products must be tempered with a realistic appraisal of the steps from initial proof of concept to a marketable device.

A trend toward greater body size in dizygotic (DZ) than in monozygotic (MZ) twins has been suggested by some but not all studies, and this difference may also vary by age. We analyzed zygosity differences in mean values and variances of height and body mass index (BMI) among male and female twins from infancy to old age. Data were derived from an international database of 54 twin cohorts participating in the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins), and included 842,951 height and BMI measurements from twins aged 1 to 102 years. The results showed that DZ twins were consistently taller than MZ twins, with differences of up to 2.0 cm in childhood and adolescence and up to 0.9 cm in adulthood. Similarly, a greater mean BMI of up to 0.3 kg/m2 in childhood and adolescence and up to 0.2 kg/m2 in adulthood was observed in DZ twins, although the pattern was less consistent. DZ twins presented up to 1.7% greater height and 1.9% greater BMI than MZ twins; these percentage differences were largest in middle and late childhood and decreased with age in both sexes. The variance of height was similar in MZ and DZ twins at most ages. In contrast, the variance of BMI was significantly higher in DZ than in MZ twins, particularly in childhood. In conclusion, DZ twins were generally taller and had greater BMI than MZ twins, but the differences decreased with age in both sexes.

For over 100 years, the genetics of human anthropometric traits has attracted scientific interest. In particular, height and body mass index (BMI, calculated as kg/m2) have been under intensive genetic research. However, it is still largely unknown whether and how heritability estimates vary between human populations. Opportunities to address this question have increased recently because of the establishment of many new twin cohorts and the increasing accumulation of data in established twin cohorts. We started a new research project to analyze systematically (1) the variation of heritability estimates of height, BMI and their trajectories over the life course between birth cohorts, ethnicities and countries, and (2) to study the effects of birth-related factors, education and smoking on these anthropometric traits and whether these effects vary between twin cohorts. We identified 67 twin projects, including both monozygotic (MZ) and dizygotic (DZ) twins, using various sources. We asked for individual level data on height and weight including repeated measurements, birth related traits, background variables, education and smoking. By the end of 2014, 48 projects participated. Together, we have 893,458 height and weight measures (52% females) from 434,723 twin individuals, including 201,192 complete twin pairs (40% monozygotic, 40% same-sex dizygotic and 20% opposite-sex dizygotic) representing 22 countries. This project demonstrates that large-scale international twin studies are feasible and can promote the use of existing data for novel research purposes.

We are social animals that exist in networks of family, friends and acquaintances. The size and quality of these networks and the environments within which they are embedded have profound influences on mental health. Community psychiatry is about shaping the content and delivery of mental healthcare to take account of this reality. It necessarily involves efforts to improve network support including, for example, family interventions, supported employment and peer support. Efforts to tackle stigma and to mitigate toxic environments are also essential. Closing asylums and developing systems to deliver care to people's homes is a job started, not job done.

The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

This chapter focuses on the epidemiological study of major psychiatric illnesses among migrant groups and their offspring. The main focus is on psychotic disorders, for which there is most evidence of elevated rates in immigrant groups and their offspring. However, the evidence with regard to other psychiatric outcomes, such as common mental disorders, suicide and post-traumatic stress disorder (PTSD), is also considered. Potential policy recommendations are proposed to address the excess morbidity of mental illness in some immigrant and black and minority ethnic (BME) groups in the UK. Several hypotheses have been raised to explain elevated rates of psychotic disorders in immigrant groups and their offspring. The chapter reviews each hypothesis. Pathways to care for BME populations have been observed to differ from those of the white British group. The risk of suicide in BME groups appears to vary by sex and ethnicity.

According to one definition of social exclusion, ‘An individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives’ (Burchardt et al, 2002, p. 30). These key activities include education, employment, access to leisure facilities and civic participation. As this book documents, people who have mental illness are often excluded from some if not all of these activities. Those with the more severe forms of disorder are unlikely to be employed, more likely to reside in shared and subsidised accommodation, live in material poverty, rely on welfare benefits, and have restricted social networks and limited access to opportunities and leisure facilities in the community. Explaining this exclusion is tricky because it clearly arises in part from the nature of mental illness. Some of the more severe disorders begin in childhood and impair educational attainment that in turn limits occupational opportunity in adult life; people with depression withdraw from social contact and those with chronic schizophrenia neglect their environment. But clearly, as the term exclusion implies, much of the problem lies not with the mentally ill person but with the rest of us – how we structure society, the rules and regulations that facilitate access to education and employment, and how we go about organising assistance for the disadvantaged. Some mentally ill people, coming from a migrant group perceived as competing for jobs and resources or who are marginalised because they do not speak English or have a black skin, can have a double or triple whammy, as evidenced by the striking over-representation of some of these groups in coercive treatment settings (Bermingham et al, 1996; Coid et al, 2000; Audini & Lelliott, 2002).

How we organise care is itself confounded by our prejudices and beliefs about the capabilities of the mentally ill person and how much we generalise from observing a specific impairment to an assumption of global incompetence. On the one hand is the view that the affected individual is essentially powerless to change their state and the caring response is therefore one of doing ‘for’ the individual.

Early specialised care may improve short-term outcome in first-episode non-affective psychosis, but it is unclear if these benefits endure.

Aims

To assess the long-term effect of early intervention in psychosis.

Method

Individuals with first-episode psychosis were randomised to specialised care or care as usual (trial number: ISRCTN73679874). Outcome after 5 years was assessed by case-note review.

Results

There were no significant differences in the admission rate (coefficient 0.096, 95% CI −0.550 to 0.742, P = 0.770) or the mean number of bed days (coefficient 6.344, 95% CI −46 to 58.7, P = 0.810).

Conclusions

These findings that specialist intervention did not markedly improved outcome at 5 years accord with those from a larger OPUS study. The sample size of this study was small and these results should be generalised with caution. More research is needed.

There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness.

Aims

To compare the costs and cost-effectiveness of an early intervention service in London with standard care.

Method

Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness.

Results

A total of 144 people were randomised. Total mean costs were £11 685 in the early intervention group and £14 062 in the standard care group, with the difference not being significant (95% CI –£8128 to £3326). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective.

Conclusions

Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.

Background – People suffering from schizophrenia have markedly increased physical morbidity and mortality. A poor diet and sedentary lifestyle make a significant contribution to this ill health. Healthcare professionals need to include assessments of diet and to promote a ‘healthy living’ lifestyle. Aims – To describe the dietary habits and cardiovascular risk factors of people with chronic schizophrenia living in supported accommodation and to audit the provision of cardiovascular health screening in this population. Method – The dietary habits of 69 people with chronic schizophrenia living in community settings were assessed. Tobacco smoking, body mass indices and waist circumference were also measured. The dietary behaviour of patients living in high care settings with care staff present every day was compared with those in low care settings. Results – Residents in both levels of care made poor dietary choices. Patients in high care were consuming more fast food than those in low care. The dietary habits of men and women in both levels of care were worse than reported by surveys of the general population in England. All patients had seen their GP in the previous year though only 3 had received diabetes screening and fewer than half had lipid profiles. Conclusions – People with schizophrenia do not improve their diet just by the provision of healthy food as was the case in high care settings. Secondary care services must address physical health monitoring as well as mental health if the increased mortality of patients with schizophrenia is to be addressed effectively. More effective interventions are necessary to improve and sustain a healthy diet.

The provision of early intervention services for people with psychosis is UK government policy, although evidence for benefit of such services is sparse.

Aims

To evaluate the effects of a service providing specialised care for early psychosis (the Lambeth Early Onset team) on clinical and social outcomes, and on service user satisfaction.

Method

One hundred and forty-four people with psychosis, presenting to mental health services for the first or second time (if previously failed to engage in treatment), were randomly allocated to care by the early onset team or to standard care. Information was obtained on symptoms, treatment adherence, social and vocational functioning, satisfaction and quality of life. Relapse and rehospitalisation data have been reported separately.

Results

Outcomes for the participants treated by the early onset team were significantly better at 18 months for aspects of social and vocational functioning, satisfaction, quality of life and medication adherence. Symptom improvement did not significantly differ between the groups.

Conclusions

The provision of specialised care for early psychosis can achieve better outcomes. The study therefore provides support for current policy.

Surveys using clinical-type interviews have documented a high rate of depression among working-class women, and this is discussed in the light of a recent survey in an inner-city area. While women with caseness of depression contacting a psychiatrist did not differ in number of core depressive symptoms from those who did, they did in certain characteristics that would make them worrying for a general practitioner to deal with. It is concluded that there is a considerable overlap in the severity of depressive conditions between those seen by psychiatrists and those defined as cases in population surveys; any differences that do exist may relate more to the way symptoms are expressed than to the severity of the depressive disorder as such.

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